查看文章

We measured the frequency of unanticipated death among patients discharged from the emergency department (ED) and reviewed these cases for patterns of potential preventable medical error.

This was a retrospective cohort of ED patients who were discharged to home from an urban tertiary-care facility after their evaluation, with subsequent case review. Subjects were aged 10 years and older, representing 387,334 visits among 186,859 individuals, February 1994 through November 2004. The main outcome was mortality. Deaths were assessed for relatedness to the last ED visit, whether the death was expected, and whether there was possible medical error. Deaths that were unexpected and related to the ED visit were analyzed using grounded theory to identify common themes among these cases. Error cases were identified as a subset of this group.

We identified …